Managing a Complex Case of Bipolar Disorder in a Patient With Recurrent Hospitalizations

Bipolar disorder type 1 (BD-1) is a complex psychiatric disorder characterized by recurrent episodes of mania and depression. While manic episodes typically present with classic symptoms such as impulsivity, elevated mood, and increased energy, atypical presentations are not as common and when encountered may pose diagnostic challenges. In addition, multiple previous hospitalizations can prove for a more nuanced case with a potentially worse prognosis. This clinical case study explores the atypical clinical presentation of a 22-year-old Hispanic male with BD-1 and discusses the challenges associated with the correct diagnosis and recognition of this disorder. Typical BD-1 symptoms consist of depressive and manic episodes. The mania can encompass elevated mood, increased energy, racing thoughts, decreased need for sleep, grandiosity, and impulsivity. The typical depressive episodes consist of fatigue, low mood, loss of motivation, changes in appetite or weight, and even suicidal thoughts. Atypical symptoms consist of a mixture of both mania and depression at once, psychosis, present with seasonal patterns, anxious distress, catatonia, and rapid cycling of mood. The patient, with a medical history of BD-1, anxiety, polysubstance abuse, and multiple inpatient psychiatric hospitalizations presented to the emergency department via involuntary hold due to threats of suicidal behavior. Upon arrival, he presented with a myriad of typical and atypical acute manic symptoms including severe agitation, disorganization, anxiety, pressured speech, and rapid mood cycling. Throughout his admission he demonstrated extreme episodes of agitation, making threats of physical violence towards staff, attempting self-injury, behaving violently towards others, and displaying impulsivity as well as grandiosity despite receiving his long-acting injectable neuroleptic medication just three weeks prior to his hospitalization. Scheduled medication treatment during his inpatient hospitalization included a combination of risperidone, thorazine, divalproex sodium, mirtazapine, clonazepam, and temazepam. This clinical case underscores the importance of recognizing both typical and atypical presentations of manic episodes in BD-1 as well as the challenges involved in the treatment of a patient with severe and refractory symptoms requiring frequent hospitalizations.